Radiation therapy for nonmetastatic medically inoperable upper-tract urothelial carcinoma

Abstract

Background: The standard management for upper urinary tract urothelial carcinoma (UTUC) is radical nephroureterectomy (RNU). However, some patients cannot undergo this procedure for several reasons, such as unresectable disease, old age, and multiple comorbidities. Our study explored the potential safety and effectiveness of radiotherapy as a curative treatment for UTUC patients unfit for surgery. Methods:The data of patients treated with radiotherapy between December 2017 and November 2019 were retrospectively reviewed. For the literature review, computerized PubMed Medline, Index Medicus, and Web of Science databases and reference lists from the identified publications of interest were used. And "upper-tract urothelial carcinoma" and "radiotherapy" were used as key words in the search. Results:We describe 8 patients with UTUC who were treated with radiotherapy. The median follow-up time was 13.5 months (range, 8.6-30.9 months). Local tumor control was achieved in all patients. However, distant metastases were observed in 2 patients with T3-4/N+ status. One patient had T4 status and the other had N2+ status. The patients died of tumor progression at 15.0 and 17.7 months. In addition, the other 6 patients who were still alive had relatively early-stage tumors without nodal involvement. Regarding acute toxicity, according to the CTCAE v5.0, mild side effects were noted, including grade 1 nausea and diarrhea.Four patients developed mild anemia, generally of grade 1-2. One patient experienced grade 3 anemia, but it was manageable and improved with symptomatic support. In addition, no grade 4 acute or late toxicities were observed. No significant long-term impairment of renal function occurred.Conclusions: For patients with nonmetastatic UTUC who are not suitable for surgery, radiotherapy is a safe treatment and can achieve good local tumor control.

Upper Tract Urinary Carcinoma: A Unique Immuno-Molecular Entity and a Clinical Challenge in the Current Therapeutic Scenario

“…RT may offer a safe therapeutic alternative in such patients with nonmetastatic UTUC who cannot tolerate or refuse surgery. 74…”

“…73 RT may offer a safe therapeutic alternative in such patients with nonmetastatic UTUC who cannot tolerate or refuse surgery. 74 Therapeutic Approaches: Advanced Disease Role of CT in Metastatic Disease. Since limited data are available on management of advanced-stage UTUC, evidence is mainly extrapolated from BC literature and supported by retrospective studies demonstrating that the location of primary tumor (lower vs upper urinary tract) do not significantly affect PFS and OS in patients with metastatic UC treated with platinum-based combinatory approaches.…”

Case report: Stereotactic MR-guided adaptive radiotherapy for inoperable urothelial carcinoma at the renal pelvis

“…Stereotactic body radiotherapy is another technique that can be utilized in tumors at the renal pelvis as a tumor boost after conventional radiotherapy or as a single definitive treatment. Conventional fractionated radiotherapy of 48.0–52.8 Gy in 20–22 fractions followed by partial stereotactic ablative boost radiotherapy 24.0–30.0 Gy in 3–5 fractions at the gross tumor, which had a total biological equivalent dose of 107.5–108.7 Gy when assuming α/β ratio of 10, was presented in a case series with three patients of UTUC at the renal pelvis ( 18 ). Patients treated with this two-phase regimen were alive without disease after 8.6–30.9 months of follow-up and had manageable toxicity without renal function impairment or ureteric stricture ( 18 ).…”

“…Conventional fractionated radiotherapy of 48.0–52.8 Gy in 20–22 fractions followed by partial stereotactic ablative boost radiotherapy 24.0–30.0 Gy in 3–5 fractions at the gross tumor, which had a total biological equivalent dose of 107.5–108.7 Gy when assuming α/β ratio of 10, was presented in a case series with three patients of UTUC at the renal pelvis ( 18 ). Patients treated with this two-phase regimen were alive without disease after 8.6–30.9 months of follow-up and had manageable toxicity without renal function impairment or ureteric stricture ( 18 ). Definitive treatment with stereotactic body radiotherapy of 50 Gy in four fractions that was presented in a case report of a medically inoperable UTUC patient at the left renal pelvis had only treatable grade 1 hematuria at 3 months posttreatment without other acute or late toxicity and resulted in complete response at reevaluation at 31 months posttreatment ( 19 ).…”

“…Definitive treatment with stereotactic body radiotherapy of 50 Gy in four fractions that was presented in a case report of a medically inoperable UTUC patient at the left renal pelvis had only treatable grade 1 hematuria at 3 months posttreatment without other acute or late toxicity and resulted in complete response at reevaluation at 31 months posttreatment ( 19 ). Both reports performed daily pretreatment CBCT to ensure the patient’s position before treatment delivery ( 18 , 19 ). Thus, stereotactic MR-guided radiotherapy could be a promising treatment for definitive radiotherapy, since it could maximize the target dose while sparing the dose to OARs by daily adaptive planning.…”